Students, health care fall into ‘residency gap’

JAKE DANNA STEVENS / TIMES-SHAMROCK TCMC student Seon Lee pulls down a letter from a lantern as she finds out what university she will go to next during Match Day.

Match Day, March 17, is a pivotal point for our fourth-year medical students. They learn where they will spend the next three or more years in residency training.

Last year, according to the National Resident Matching Program, 42,370 new medical school graduates vied for 30,750 residency positions, meaning the 2016 Match left 11,620 new M.D.s, most of them graduates of foreign medical schools, without a residency. This included 533 graduates of American schools. A doctor cannot obtain a license to practice medicine without completing a residency. The number of unmatched students is projected to grow further in the coming years.

Given the well-documented physician shortage, the mismatch between graduates and residency training is a disturbing trend.

To understand how we arrived at this bottleneck, a bit of history is helpful. Today’s system for funding residency programs was born in the 1960s, when Medicare began making payments to teaching hospitals for the added cost of training residents. The government responded to the physician-shortage predictions prevalent at the time.

When it was first established, Medicare support for graduate medical training was open-ended, meaning hospitals could add positions as they deemed necessary.

In 1980, the Graduate Medical Education National Advisory Committee published a report projecting a physician “glut,” partly based on the erroneous assumption that new managed-care models of health care delivery would produce a surplus of 70,000 physicians by 1990. Prompted by this and similar reports, Congress acted in 1997 to place a cap on the number of residency positions for which Medicare would pay. That cap remains, even though the “physician glut” failed to materialize.

Although hospital systems have tried to close the gap with private money, graduate medical education is far too costly to cover by patchwork means. With salary and benefits, plus administrative costs, the average cost to train a single resident is $120,000 to $145,000 annually, according to ECG Management Consultants in Boston. That means adding just one residency position would cost about half a million dollars or more in four years, a cost the institution would then be obliged to shoulder in perpetuity.

Legislative remedies have been proposed and several bills have been drafted, but have not moved forward because of the cost. The Association of American Medical Colleges has called upon medical schools to institute changes in admissions and curriculum intended to address a subset of the physician shortage problem, “maldistribution,” the phenomenon that finds most physicians clustered in large urban areas, leaving “care deserts” in large swaths of our country. To this end, the association calls for holistic review of medical school applicants, with a particular focus on identifying students interested in working in rural and underserved communities. It also recommends a curriculum geared to produce service orientation and cultural competency in students, in addition to imparting the more traditional skills like taking a patient history and conducting a physical exam.

I am proud that Geisinger Commonwealth School of Medicine, since its inception, has embraced the policies championed by the AAMC. Our admissions process is weighted in favor of local students and our curriculum is designed to encourage community engagement and to help our students take a holistic, person-centered view of their future patients.

I am also pleased that the school is taking another action prescribed by the educational reformers — that of understanding and addressing the health care workforce needs of our community.

The story of residency funding since the 1960s has been marred by erroneous projections driven by improperly examined presumptions. For this reason, some experts studying the residency gap have “rejected national projections but agreed with regional shortage and specialty shortage projections.” In sum, they urge institutions to know their neighbors’ needs.

Geisinger Commonwealth is doing that by launching a health care workforce needs assessment, to be conducted by the Institute for Public Policy and Economic Development led by Teri Ooms. The assessment will identify geographic areas and specialties in which the physician shortage may be acute in our region, giving us a foundation upon which to plan new residency programs in the Scranton/Wilkes-Barre area. With this information, the medical college can work with partners such as the Wright Center to develop regionally engaged and relevant new residency programs, and to identify ways to support the costs.

This community’s medical college was founded to meet the region’s health care needs and help solve access-to-care problems unique to it — the very mandates AAMC suggests for all medical education. As Match Day 2017 approaches, we know our mission will serve our students well and help them secure their preferred residency. Let us hope that, in the future, we may say that of all deserving applicants.

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